EMPLOYEE REQUEST FOR ABSENCE FORM (For absences greater than 5 consecutive days only.)
Name: _____________________________________________________________ Building: _____________________________________
Classified
Position: __________________________________________________ Absence Reason Type: Illness
Family Illness
Certified
Personal FMLA Absence Begin Date: ________________ Absence End Date: _________________ Dates of Paid Leave: From___________________ To_____________________ Dates of Unpaid Leave*: From______________________ To_____________________ Please note that a physician's note is required for any illness or FMLA related absence of
more than 5 consecutive days.
Reason for Request:
_________________________________________________________________________________________________ Employee Signature Date _________________________________________________________________________________________________ Building Principal or Immediate Supervisor Granted
Denied Date _________________________________________________________________________________________________ Superintendent or Designee Granted
Denied Date *All personal leave must be used before unpaid leave can begin.
___________HR Rec’d _______Copy to AESOP _______ Board Personnel Report
_______Copy to PR _______ Extended Leave Report
_______IT Spreadsheet
12/16/16